IC Quick Tip
Before undergoing any type of catheterization, patients can ask for their urethra to be anesthesized. A 2% lidocaine jelly is commonly used and can reduce discomfort associated with catheterization.

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About Bladder Instillations

During a bladder instillation, the bladder is filled with
a therapeutic solution that flows in through a narrow tube inserted through
the urethra and into the bladder, called a catheter. The instillation is
held for varying periods of time, from a few seconds to 15 minutes or more
(known as "dwell time"), before being drained or voided. Although most physicians
use the "adult" size catheters, if patients have discomfort or difficulty
with it, they can request the use of a smaller "pediatric" catheter.

The purpose of the instillation varies, depending on what is instilled.
Some solutions are thought to coat and protect the bladder, while others
are thought to suppress inflammation. Many physicians instill combinations
of ingredients that they believe work better than a single agent. Patients
sometimes refer to these as "cocktails."

IC patients may want to ask their doctor to describe all of the ingredients
in the instilled solution, and what each is for. This knowledge is important
because many IC patients have drug allergies and sensitivities. Should
you have a reaction to one of the components, your doctor can adjust the
combination to suit your particular needs.

Dimethyl sulfoxide was the first of two therapies approved by the US FDA
for the treatment for IC in the early 1970's. Its use, however, has quickly diminished due to the growing popularity of Rescue Instillations and research that suggests that DMSO can be damaging to the bladder muscle. Many clinics no longer use DMSO treatments.

DMSO is a dilute, sterile, and purified version
of a chemical that was used for many years as an industrial solvent before
being found to have anti-inflammatory, analgesic, muscle relaxant, mast
cell stimulation and collagen dissolution properties. The FDA has approved
a solution of DMSO (brand name: RIMSO-50) for bladder instillation in treating
IC. It is thought to work by reducing inflammation and is estimated to be
effective in about 50% of cases

Research presented in 2002 at the AUA Annual Meeting now suggests that DMSO has the potential of causing damage to the muscle of the bladder when used at the 50% dosage. In "DMSO - Does it change functional properties in the bladder wall" (Diethild Melchior*, C Subah Packer, Tomalyn C Johnson, Martin Kaefer, Indianapolis, IN) researchers tested various concentrations of DMSO on strips of bladder muscle to try to determine what, if anything, the DMSO did to muscle. They found that DMSO triggered intense muscle contractions and, at doses higher than a 30% solution, caused what appeared to be long-lasting contractions that could be irreversible. Since the normal FDA approved dosage used for humans is 50%, researchers suggested that the dosage be reduced to, at most, 25% to avoid any possibility of muscle damage.

A course of treatment involves six to 8 weekly instillations. Usually, patients will have one to two courses of therapy. DMSO is rarely used as a long term therapy, particularly if patients show no response to treatment.

DMSO is administered via catheterization after the urethra
has been anesthetized with a 2% lidocaine jelly. Once it is placed into
the bladder, patients are instructed to hold the medication for 15-20
minutes before urinating.

Some patients who respond to DMSO notice improvement of symptoms immediately.
Others improve three or four weeks after the six to eight week cycle of
treatments. If improvement is seen, the cycle can be repeated according
to the needs of the patient.

A few patients experience intense burning
or an exacerbation of symptoms for a short time after the first treatment
(the result of mast cell stimulation), which often subsides. Many of these
patients see improvement in their IC symptoms after subsequent treatments.
Many experience no discomfort. The most common side effect is a garlic-like taste in the mouth and
an odor to the breath and body, occurring a few hours after instillation
and continuing for about a day (2). About 10% of patients report bladder
spasms and irritability (3). The manufacturer of RIMSO-50 strongly recommends
that patients have "slit-lamp eye examinations" before and after treatment
to verify that no eye lens opacity (clouding) has occurred with treatment.
DMSO is teratogenic in animals. It should not be used during pregnancy,
within four weeks of a bladder biopsy or if infection is present (4).

DMSO research studies report a 35-40% relapse rate after a 4-8 week
course of treatment. However, 50-60% of those patients responded favorably
to additional DMSO treatments (1). For those who relapse, DMSO may be
administered in one to two month intervals (maintenance therapy), depending
upon their symptoms. If patients do not respond to DMSO initially, it
may be combined with hydrocortisone, heparin and sodium bicarbonate. Please
check the on-line ICN research library for the latest research studies
on DMSO.

Heparin is chemically similar to constituents of the GAG layer. It is believed
to have anti-inflammatory and "surface protective" action when instilled
into the bladder. So, like the oral medication ELMIRON®, it has been used
to help "recoat" the bladder.

Heparin is instilled in the bladder via catheter in a manner similar
to DMSO. While it is usually done in a doctor's office at first, most
patients find they can easily learn to self-catheterize for home treatment.
Research by Parsons (5) shows that heparin, when administered three times
per week for three months resulted in clinical remission of symptoms in
56% of patients and the remission was maintained in 80%-90% for up to
one year, if treatment was continued at a maintenance level.

It is common for DMSO and heparin to be instilled in the bladder together.
Heparin instillations are also often used in a treatment program that
includes oral ELMIRON®. Please check the ICN Research Library for the
latest research studies on heparin.

In February 1995, the Bioniche Pharmaceutical Company (London, Canada) announced
a new product for the treatment of interstitial cystitis that is not yet
approved for use in the USA. In a small study of 25 patients treated at
the Urology Clinic of Queens University in Canada (6), a positive response
was experienced by 56% of participants by week four. At week 12, 71% of
the participants showed a partial positive response. A preliminary report
about this drug was presented at an American Urological Association meeting
in Las Vegas in April 1995.

The main ingredient in Cystistat is hyaluronic acid. Hyaluronic acid
occurs naturally in the connective tissues of the human body and has many
properties in common with other drugs used in the treatment of IC, such
as heparin and ELMIRON. A form of hyaluronic acid has been used for many
years to protect against corneal loss during eye surgery. It is believed
that Cystistat coats the lining of the bladder and protects it from irritating
substances in the urine.

It is instilled directly into the bladder via catheter in a doctor's
office. Bioniche recommends that patients receive the first four treatments
on a weekly basis, followed by one treatment monthly until symptoms resolve.
Most people don't experience relief until the fifth or sixth treatment.
Preliminary studies found that most patients had symptomatic improvement
after 12 weeks. Long-term trials need to be completed in order to better
evaluate its effectiveness.

Cystistat has not been approved by the FDA, however, it is available
on a limited basis to IC patients in both Canada and the US. To find out
more about Cystistat's availability, Bioniche can be contacted by your
doctor through its toll-free number, 1-800-567-2028. Your urologist will
be provided with information about the therapy as well as purchase instructions.

Silver nitrate is an "antiseptic" bladder wash that is now rarely, if ever, used for IC. Why? When silver nitrate first became popular, doctors believed that it would destroy any bacteria or infection that could be triggering IC. However, we now know that IC is not bacterial in nature. Rather, IC is much more like a wound struggling to heal. Our goal in therapy is to soothe the bladder, not irritate it further. If your physician is suggesting silver nitrate, we strongly encourage you discuss the use of a "rescue instillation" and/or various oral medications first.

One of the most caustic medications placed in the bladder, silver nitrate actually damages (and/or strips off) the bladder lining. One of the most painful bladder instillations
available, it is usually administered in a manner similar to that of DMSO or heparin,
but under general anesthesia.

Silver nitrate was thought to work by first attacking or stripping the
bladder lining. It was believed to trigger the body's
immune system to step in and start the healing process. These antiseptic
chemicals are also antibacterial in that they kill organisms present in
the bladder.

Some patients have been successfully treated with these drugs
but the frequent, painful treatments usually must be done under general
anesthesia-- which carries some risk. This cannot be used in people who
have urinary reflux, a condition in which urine flows backward up the
ureters and into the kidneys. With the recent increase in the number and
variety of other IC treatments available, this is now rarely used.

Clorpactin® (WCS-90) solutions
are commonly used throughout the medical community as a lavage or wash
that, at very low concentrations, can clean wounds, sinuses, and remove
the necrotic debris from massive infections. During surgical procedures
(i.e. appendix rupture), it is used as an irrigant because it kills bacteria,
fungi, and some viruses. Recent research studies have shown that it also
has effectiveness in the treatment of oral diseases, such as canker sores,
gingivitis and periodontal disease.

Yet,
for the past twenty years, incorrect information abut Clorpactin has circulated
throughout the IC community that it is "bleachlike" probably
from the similarity of its name to chlorine or Clorox. It has also been
used by some physicians at a painful dosage that is not recommended by
the company or early research.

Grannum Sant, MD and
Dennis La Rock, in "Intravesical Therapies for Interstitial Cystitis"
described the early use of Clorpactin® in the bladder. "The
initial rationale for the use of Clorpactin in the 1950's was based on
the similarity between the 'classic form' of interstitial cystitis with tuberculosis
of the bladder. Clorpactin® was used to treat bladder tuberculosis
and this led to its use in interstitial cystitis based on the unsubstantiated
belief that IC is caused by unidentified bacteria." Yet, even
in those earliest days, pain was a consideration that the manufacturer
took very seriously. Alfred Globus, CEO of United- Guardian, Inc., offered
"When Clorpactin® was first used in the bladder for tuberculosis
cystitis, it was done with a 0 .33% solution. However, we found that this
concentration was too high because it caused profound pain. However, most
patients could tolerate a 0.2% solution much more comfortably and still
receive the same results after a series of 4-6 weekly instillations. Therefore,
we've only recommended the 0.2% concentration for use in the bladder."

Yet, during the 1970's,
the treatment protocol for IC was dramatically changed when researchers
in New Zealand began using a 0.4% solution as a single instillation in
combination with a hydrodistention of the bladder, rather than doing weekly
instillations at 0.2%. The New Zealand protocol was significantly more
painful and also required general anesthesia. Not surprisingly, this new
method & approach became popular in America where doctors at leading
universities began using this "more efficient" method of delivery.
Dr. Globus reiterated:

"Our recommended
course of treatment involved a series of office visits at 0.2% about
four or five days apart, filling the bladder comfortably without over
distention. In New Zealand, they deviated from this protocol by making
it a single application at 0.4% with hydrodistention. It's not only
the pain caused by the 0.4%, but also the act of stretching the bladder.
We did not change our viewpoint. We knew that it was too painful to
exceed 0.2% and we did not recommend that increase. The point is that
when someone changed the technique on their own ( i.e. 0.4%) that hurt
everyone. It's not just twice as difficult to tolerate, it's probably
four times as painful. The square of the increase (two squared)."

Why would it be done
at the higher dose than at the lower dose? Some care providers would argue
that it saved the cost of several office visits. Others would say that
it was as equally effective as the lower dosage. We wonder, though, if
the patient experience was disregarded. Would a patient agree to have
a therapy that was very painful when a much less traumatic method of using
the same medication was also available? Likely not. Dr. Globus continued
"When I asked one doctor how his patients reacted to the 0.4%, he
said that his patients had 'handled it.' I was surprised. Why do it at
the high dose, when a lower dose can be just as effective and not as painful."
Thus, the legitimate stories of excruciating procedures and pain became
commonplace.

Bacillus Calmette Guerin

BCG is used
in the treatment of bladder cancer and, for a brief time, was used to treat IC. In June of 1998, the first double blind placebo
study research results were released by researchers at the Department of
Urology, William Beaumont Hospital, Royal Oak, Michigan, USA. Peters, Diokno
et al. (7) report a 60% BCG response rate. However, a much larger national study performed by the ICCTG found little effectiveness. It is now rarely used for IC.